Exam 5 AH3 Questions

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

C. Assess the airway

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? A. The nursing assistant elevates the head of the bed above 30 degrees. B. The nursing assistant places a pillow under the patient's head. C. The nursing assistant places rolled towels under the patient's shoulders. D. The nursing assistant covers the patient with sterile linens.

B. The nursing assistant places a pillow under the patient's head.

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.

B. The right foot's capillary refill is less than 2 seconds.

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? A. Impaired skin integrity B. Risk for fluid volume overload C. Risk for infection D. Ineffective coping

C. Risk for infection

The _____________ layer of the skin helps regulate our body temperature. A. Epidermis B. Dermis C. Hypodermis D. Fascia

C. Hypodermis

During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit

D. Low sodium, high potassium, high glucose, high hematocrit

True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

False

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

A. 1st degree (superficial) burn

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

A. 63%

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

A. 921 mL/hr

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

A. Acute kidney injury B. Dysrhythmia C. Iceberg effect E. Bone fractures

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

A. Carbonaceous sputum B. Hair singeing on the head and nose D. Bright red lips E. Hoarse voice F. Tachycardia

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: A. Elevate and extend the extremities B. Elevate and flex the extremities C. Keep extremities below heart level and extended D. Keep extremities level with the heart level and flexed

A. Elevate and extend the extremities

What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

A. Fluid volume B. Respiratory status

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: A. Hemoglobin and myoglobin B. Free iron and white blood cells C. Protein and red blood cells D. Potassium and Urea

A. Hemoglobin and myoglobin

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: A. Place the patient in High Fowler's positon. B. Prep the patient for escharotomy. C. Prep the patient for fasciotomy. D. Prep the patient for intubation. E. Place a pillow under the patient's neck. F. Obtain IV access at two sites. G. Restrict fluids.

A. Place the patient in High Fowler's positon. B. Prep the patient for escharotomy. D. Prep the patient for intubation. F. Obtain IV access at two sites.

You are about to provide care to a patient with severe burns. You will don:* A. gloves B. goggles C. gown D. N-95 mask E. surgical mask F. shoe covers G. hair cover

A. gloves C. gown E. surgical mask F. shoe covers G. hair cover

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."

B. "I think it has been 10 years or more since he had a tetanus shot."

You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? A. "Patients are most likely to present with cyanosis around the lips and face." B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." C. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." D. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body."

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen

B. 100% oxygen via non-rebreather mask

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

B. 2nd Degree (partial-thickness)

Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.

B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso.

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? A. Emergent B. Acute C. Rehabilitative

B. Acute This phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: SATA A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection

B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? A. Swelling and pain on the area distal to the burn B. Burning, gnawing sensation pain in the stomach and vomiting C. Dark red or gray sores on the soles of the feet D. Difficulty swallowing and gagging

B. Burning, gnawing sensation pain in the stomach and vomiting

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

B. High calorie, high protein and carbohydrate

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? A. IM morphine B. PO morphine C. IV morphine D. Subq morphine

C. IV morphine

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will: A. Decrease the temperature by 5-10 degrees to prevent hyperthermia. B. Leave the temperature setting. C. Increase the temperature to a minimum of 85'F.

C. Increase the temperature to a minimum of 85'F.

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: A. Increase the IV fluids B. Continue to monitor the patient C. Decrease the IV fluids D. Notify the physician of this finding

D. Notify the physician of this finding